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Colorado Advance Medical Directive Form 2

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This Colorado advance medical directive form provided by Colorado Advance Directives Consortium is a living will for surgical treatment.

Colorado Advance Medical Directive Form 2
Colorado Advance Medical Directive Form 2
ADVANCE DIRECTIVE FOR MEDICAL / SURGICAL TREATMENT
(Living Will)
On completion, give copies to your physician, family members, and Healthcare Agent. If you wish to revoke or replace this
document, mark it clearly as “Revoked” or destroy it and all its copies, if possible. If you do not understand the choices and
options, seek advice from a healthcare provider or other qualified advisor.
I. DECLARATION
I, _______________________________________, am
at least eighteen years old and able to make and
communicate my own decisions. It is my direction that
the following instructions be followed if I am diagnosed
by two qualified doctors to be in a terminal condition or
Persistent Vegetative State.
A. Terminal Condition
If at any time my physician and one other qualified
physician certify in writing that I have a terminal
condition, and I am unable to make or communicate my
own decisions about medical treatment, then:
1. Life-Sustaining Procedures (initial one):
(Initials) I direct that all life-sustaining
procedures shall be withdrawn and/or withheld, not
including any procedure considered necessary by my
healthcare providers to provide comfort or relieve pain.
(Initials) I direct that life-sustaining procedures
shall be continued for/until (state timeframe or goal):
2. Artificial Nutrition and Hydration
If I am receiving nutrition and hydration by tube, I direct
that one of the following actions be taken
(initial one)
:
(Initials) Artificial nutrition and hydration shall
not be continued.
(Initials) Artificial nutrition and hydration shall
be continued for/until (state timeframe or goal):
(Initials) Artificial nutrition and hydration shall
be continued, if medically possible and advisable
according to my healthcare providers.
B. Persistent Vegetative State
If at any time my physician and one other qualified
physician certify in writing that I am in a Persistent
Vegetative State, then:
1. Life-Sustaining Procedures (initial one):
(Initials) I direct that life-sustaining procedures
shall be withdrawn and/or withheld, not including any
procedure considered necessary by my healthcare
providers to provide comfort or relieve pain.
(Initials) I direct that life-sustaining procedures
shall be continued for/until (state timeframe or goal):
2. Artificial Nutrition and Hydration
If I am receiving nutrition and hydration by tube, I direct
that one of the following actions be taken
(initial one)
:
(Initials) Artificial nutrition and hydration shall
not be continued.
(Initials) Artificial nutrition and hydration shall
be continued for/until (state timeframe or goal):
(Initials) Artificial nutrition and hydration shall
be continued, if medically possible and advisable
according to my healthcare providers.
II. OTHER DIRECTIONS
Please indicate below if you have attached to this form
any other instructions for your care after you are
certified in a terminal condition or Persistent Vegetative
State (for instance, to be enrolled in a hospice program,
remain at or be transferred to home, discontinue or
refuse other treatments such as dialysis, transfusions,
antibiotics, diagnostic tests, etc.)
(initial one)
:
(Initials) Yes, I have attached other directions.
(Initials) No, I do not have any other directions.
III. RESOLUTION WITH MEDICAL
POWER OF ATTORNEY
(initial one)
(Initials) My Agent under my Medical Durable
Power of Attorney shall have the authority to override
any of the directions stated here, whether I signed this
declaration before or after I appointed that Agent.
(Initials) My directions as stated here may not
be overridden or revoked by my Agent under Medical
Durable Power of Attorney, whether I signed this
declaration before or after I appointed that Agent.
Pursuant to Colorado Revised Statute 15-18.101–113
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Colorado Advance Medical Directive Form 2
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